The Role of Colonic Stents in Obstructive Metastatic Colorectal Cancers

J Soc Colon Rectal Surgeon (Taiwan) March 2009 Original Article The Role of Colonic Stents in Obstructive Metastatic Colorectal Cancers Hua-Che Chiang Wen-Chien Ting Willian Tzu-Liang Chen Division of Colorectal Surgery, Department of Surgery, China Medical University Hospital, Taiwan Key Words Colonic stent; Colon obstruction Purpose. Self-expandable metallic stents (SEMS) have been widely used in obstructive lesions. They are an alternative treatment for obstructive colorectal tumors. In this article, we retrospectively review our experience with placement of colonic stents for palliative treatment of obstructive metastatic colorectal cancers and inoperable colorectal cancers. Methods. From March 2004 to March 2007, we inserted SEMS in 15 patients. A retrospective chart review was undertaken at the China Medical University Hospital. For all patients, surgical treatment was not considered initially or the patients refused surgery. We analyzed the technical and clinical success rates of stent placement. All patients were characterized in terms of age, localization of tumor, complications, morbidity and mortality, and the necessity for further interventions. Results. Our subjects included eight males and seven females, with a mean age of 66 years (range 42-94 years). Sites of the lesion included six upper rectum, four rectosigmoid junction, three sigmoid colon, one descending colon, and one splenic flexure of colon. The stents were successfully implanted in 12 of the 15 patients and bowel obstruction relieved in all patients; the technical success rate was 80% and clinical success rate was 60%. Two patients with stent related perforations required emergency operation on the 4th or 18th day after stent implantation. The mean survival time (stent implantation to death) of the ten stage IV patients (n = 10) was 7 months (range 1-16months). Four patients had complications. In general, there was no stent-related mortality. Conclusions. Self-expandable metallic stents in patients with malignancy-induced colorectal obstruction is technically feasible, but it has higher morbidity rate in our study. Colonic stent is an alternative option in treatment of obstructed colorectal malignancy, but is not encouraged for every patient. When use of SEMS, surgeon or gastroenterologist should evaluate the clinical benefits and cost effectiveness for the patient. [J Soc Colon Rectal Surgeon (Taiwan) 2009;20:13-19] Obstruction of the large bowel frequently results from pelvic neoplasms, including colorectal, ovarian, prostate, and bladder cancers. In the past, the most common treatment for these diseases was resection of the tumor or a diverting colostomy. In cases with recurrent disease, resection is not always possible. Surgery is performed for palliation, rather than curative intent. Moreover, patients who present with an acute obstruction of the large bowel are frequently in a poor general condition, and these cases are associated with higher surgical mortality and morbidity rates. Received: December 25, 2008. Accepted: March 2, 2009. Correspondence to: Wen-Chien Ting, Division of Colorectal Surgery, Department of Surgery, China Medical University Hospital, Taiwan, No. 2, Yu-Der Road, Taichung 404, Taiwan. Tel: +886-9-6620-2266, +886-4-2205-2121-1638; Fax: +886-4-2202-9083 13

14 Hua-Che Chiang, et al. J Soc Colon Rectal Surgeon (Taiwan) March 2009 Recent reports indicate that a self-expandable metallic stent (SEMS) can successfully be used as an alternative procedure in the treatment of obstructive colorectal tumors. The self-expandable metallic stent, which was first described by Dohmoto et al in 1990, was initially used for decompression of obstructions in metastatic colorectal cancer patients as part of palliative care regimen. 1,2 In 1994, Tejero et al reported the use of SEMS in obstructive colorectal cancers as a bridge to surgery for possible curative resection of colorectal cancers. 3 Since then, colonic stents have been used for both palliation of obstructed metastatic colorectal cancers as well as a bridge in patients who will receive curative resection of obstructive colorectal tumors. 4-7 Currently,SEMSisusedinTaiwanwithsome cases reported in the published literature. The aim of this study is to review our experience with placement of colonic stents for palliative treatment of obstructive metastatic colorectal cancers and inoperable colorectal cancers. A water-soluble contrast enema examination was performed in all cases. This procedure allowed the endoscopist to clearly understand, before the procedure, the stricture location, length, and expected difficulties associated with tortuous bowel segments. Each patient was placed in the left decubitus or supine position and kept under intravenous general anesthesia. A double channel colonoscope was then advanced to the site of the lesion. When the lesion was identified, a guide wire was passed through the stricture under colonoscopic and fluoroscopic guidance (Figs. 1 and 3). The catheter was inserted after the guide wire was passed successfully past the lesion. Contrast medium was injected to determinate the length of the obstructive lesion. The stent was then inserted along the guide wire (Fig. 1). Finally, a colonoscope was re-inserted to confirm the patency of the stent (Fig. 2). A plain radiograph of the abdomen was taken one day after stent placement to evaluate the expansion of the stents. Materials and Methods A retrospective chart review of patients was performed at the Department of Colorectal Surgery of China Medical University Hospital, Taichung, Taiwan. From March 2004 to March 2007, a total of 15 patients received SEMS. Indications for insertion of SEMS included poor general health in patients who were not candidates for surgery, and those who refused to have surgery due to an incurable disease. All patients displayed clinical symptoms of colon obstruction. Data, including gender, age, type of disease, site of obstruction, technical and clinical success of stent placement, and complications associated with the procedure, were recorded. All patients underwent regular follow up until the patient expired. Fig. 1. Stent placing through the scopy Self-expandable metallic stent surgical procedure Fig. 2. Expansion of SEMS

Vol. 20, No. 1 Colonic Stents 15 Fig. 3. Procedure under fluoroscopic guidance 1.Contrast for the tumor length: a~b 2. guidewire was passed through the stricture and expanded:c~d Definition of successful stenting The technical success of the procedure was defined as deployment of the stent across the entire length of the stricture, patency of the stent, and clinical and radiologic relief of the obstruction. Clinical success was defined as the patient s ability to defecate and relief of obstructive symptoms without complication. Results Of the 15 patients, there were 8 males and 7 females, with a mean age of 66 years (range, 42-94 years). Sites of the lesion included the upper rectum (n = 6), rectosigmoid junction (n = 4), sigmoid colon (n = 3), descending colon (n = 1), and one splenic flexure of the colon (n = 1). The stents were successfully implanted in 12 of 15 patients (80.0%), yielding a clinical success rate of 60.0% (9/15). The mean operative time of the 12 technically successful cases was 70 minutes (range, 20-210). One patient who required two stents was in surgery 210 minutes. Port-A implantation was also performed in 2 patients (operative times, 85 min and 125 min, respectively). The mean operative time in cases where only a stent was placed (n = 9) was 48 minutes (range, 20-90). Of these 9 patients, 1 needed balloon dilatation which extended the duration of surgery to 90 minutes. In 3 patients we were unable to insert the guide wire. In the first patient, we failed to insert the guide wire due to an anatomic reason. In the second patient, we could not pass the guide wire past the splenic flexure obstruction due to a sharp splenic flexure angle. In the third case, which was a patient with ovarian cancer, there was local disease recurrence and invasion into the upper rectum, causing colonic obstruction. The guide wire was unable to pass through the obstruction. All 3 were treated with diverting stoma soon after stent failure. Four complications occurred after stenting. Two patients with stent-related perforations required emergency surgery on day 4 in one patient and on day 18 in the other patient after stent implantation. Movement of the stent out of the rectum with passage through the anus was observed in 1 patient at 3 months after stenting. the patient died 20 days after that episode in a hospice care unit. The mean survival time (stent implantation to death) for the 10 stage IV patients was 7 months (range, 1-16 months). The mean survival time of 6 patients who did not receive chemotherapy was 5 months. The mean survival time of 4 patients with chemotherapy treatment was 10 months. Two stage IV patients with chemotherapy were still alive at 9 and 12 months. One of them had another obstruction 6 months after stenting, and Hartmann s procedure was performed. In this series, except for 1 patient who died of pneumonia, all of the other patients died from disease progression. Patient details are listed in Table 1. There was no stent-related mortality. Discussion According to the literature, most common indications for the use of SEMS are as a bridge to surgery in patients with obstructed colorectal cancer and for palliative treatment of patients with obstructive disease in whom curative resection is an option 8,9 Self-expandable metallic stent implantation in our study is mainly for palliation treatment of colorectal cancer and patients with inoperable metastatic colorectal malignancy.

16 Hua-Che Chiang, et al. J Soc Colon Rectal Surgeon (Taiwan) March 2009 Table 1. Patients profile NO Sex Age Diagnosis Technical successful Clinical successful Complication Surgery Survival time (months) 1 F 90 Upper rectal ca No No Yes, colostomy 2 F 64 Ovary ca with local No No Yes, colostomy recrrence and colon obstruction 3 M 90 Splenic flexure ca, dementia No No Yes, colostomy 4 M 58 RS colon ca; liver cirrhoisis, Yes Yes No No 13 months Child C 5 M 62 Recurrent RS colon ca, Yes Yes No No 13 months 6 M 52 S-colon ca with Yes Yes No No 11 months 7 F 48 Recurrent rectal ca, Yes No Severe pain, RS junction perforation Yes,Hartmann s procedure 16 months (18th day after stent) 8 M 94 S-colon ca Yes No RS junction perforation, 4 th day after stent 9 F 46 Rectal ca with multiple liver meta 10 M 64 S-colon ca. with multiple liver meta 11 F 77 RS junctional colon ca, ECOG 4, Old CVA 12 F 55 Cervical ca with local recurrence and rectum obstruction, Yes,Hartmann s procedure 13 months Yes Yes No No 6 months Yes Yes No No 9 months Yes Yes No No 7 months Yes Yes No No 3 months 13 F 90 Rectal cancer with lung Yes Yes Dislocation No 3 months metastasis 14 M 42 D-colon ca, Yes Yes No No Alive at 9 months 15 M 53 RS junctional colon ca with Yes No Re-obstruction 6 months later Yes, Hartmann s operation Alive at 6 months Palliative treatment for colon obstruction due to malignancy is comprised of surgery (including palliative resections, colostomy, or intestinal bypass) and stent therapy. 4-7 If there is no contraindication to surgery, palliative tumor resection is the better method of choice. 10-12 When palliative surgery is contraindicated, internal bypass using colonic stent can be an option without increasing the risk of morbidity or mortality. In addition, many studies have demonstrated that placement of stent in patients with inoperable disease have much lower morbidity (< 25% vs. < 50%, respectively) and mortality (< 1% vs. < 10%, respectively) in comparison with surgical intervention. 8,9,11-14 Stent implantation provides a comparable prognosis and a favorable advantage for avoiding a colostomy. Also, the implantation of stent is a simple procedure, and is associated with a greater quality of life. 15-19 However, our study revealed a much higher morbidity (4/15, 33.3%). None of the benefits that had been published in the literature were demonstrated in our preliminary study. The reported technical and clinical success rates of this procedure are 75.0% to 100.0% and 84.0% to 100.0%, respectively. 20-22 Our study showed a comparable technical success rates (80.0%). However, only 60.0% (9/15) of our patients were considered a clinical success. In our series, we failed to insert the guide wire in 3 patients who had anatomic difficulties. In the first 2 cases we encountered sharp angulation of the splenic flexure and rectosigmoid junction, and in the third case we were unable to inserting guide wire through obstruction site. Khot et al summarized that

Vol. 20, No. 1 Colonic Stents 17 the most common reason for stent failure was an inability to place a guide wire across the lesion. 20 Another source of difficulty in SEMS implantation is lesions located high up in the colon, particularly those lesions found in the splenic flexure. 23 Stent migration is another major complication associated with the stent procedure, with a reported incidence of 10% to 12%. 20,21,23 In our study, no stent migration was observed, but an unusual case of stent dislocation out of the rectum and through the anus was observed. This occurred at the 3 months after stent placement. No further procedure was performed due to the poor general condition of the patient. Other complications related to stent placement including re-obstruction, perforation, bleeding, and pain. 20-22 Obstruction recurred after stenting in patients who received a stent that was too short to bypass the obstruction area. Repeat obstruction also was encountered in cases where poor placement of the stent resulted in inadequate upper margin. One patient experienced repeat obstruction 6 months after stenting due to tumor-related ingrowth. Other than surgery, alternative procedures can be used for tumor ingrowth obstructions, such as ablation of the obstruction and placement of an addition stent over the previous stent. 24 In our study, 2 patients suffered from stent-related perforation. The diagnosis of perforation was made on day 4 and day 18 after stent implantation, respectively. During emergency laparotomy, it was discovered that the perforation occurred at rectosigmoid junction in both cases. Based on our experience, colonic perforation should be highly suspected in the patient who complains of severe abdominal pain after stenting. Most authors have reported SEMS implantation within the left colon, but only a few reports described successful SEMS implantation within the right colon. 15-19,23,25,26 In our limited experience, we did not place SEMS in the right colon in any of our patients. However, this may be due to our small patient population. With regard to the cost effectiveness of SEMS, one SEMS costs approximately 66,000 NT dollars and the average cost for a stoma bag for one year is about 125,000 NT dollars. On this basis alone, it appears as though SEMS is more cost-effective. However, in fact, this consideration depends on whether any complication occurs intraoperatively or postoperatively. In this study, we demonstrated an acceptable technical success rate with regard to stent placement, but a much lower clinical success rate was observed. In addition, a higher morbidity rate was observed in our study compared with the published literature. However, this may be due to the limited number of cases at our center. Other disadvantages to our study include a lack of comparison with surgically treated patients, no evaluation of quality of life after stenting, and a comparison of the cost of stenting with surgery. Conclusion In our early and limited experience we demonstrated that SEMS placement in patients with malignancy-induced colorectal obstruction is technically feasible, but is associated with a high rate of morbidity. Although colonic stent can be used as palliative treatment and an alternative procedure to surgery, the only benefit is to avoid either permanent or temporary colostomy. In conclusion, colonic stent for palliative treatment of obstructive metastatic colorectal malignancy is not encouraged for every patient. All surgeons and gastroenterologists should evaluate the clinical benefits and cost effectiveness when using colonic stent. Until large prospective randomized trails have proved the superiority of the colonic stent, it should not be routinely applied for palliative treatment of obstructive metastatic colorectal malignancy. References 1. Dohmoto M, Rupp KD, Hohlbach G. Endoscopically-implanted prosthesis in rectal carcinoma. Dtsch Med Wochenschr 1990;115:915. 2. Spinelli Iý, Dal Fante M, Mancini A. Selfexpanding mesh stent for endoscopic palliation of rectal obstructing tumors: a preliminary report. Surg Endosc 1992;6:72-4. 3. Tejero E, Mainar A, Fernadez L, Tobio R, De Gregorio MA. New procedure for the treatment of the colorectal neoplastic obstructions. Dis colon Rectum 1994;37:1158-9. 4. Adler DG, Baron TH, Endoscopic palliation of colorectal cancer. Hematol Oncol Clin North Am 2002;16:1015-29.

18 Hua-Che Chiang, et al. J Soc Colon Rectal Surgeon (Taiwan) March 2009 5. Xinopoulos D, Dimitroulopoulos D, Tsamakidis K, Apostolikas N, Paraskevas E. Treatment of malignant colonic obstructions with stent and laser. Hepatogastroenterol 2002; 49:359-62. 6. Harris GJC, Senagore AJ, Lavery IC, Fazio VW. The management of neoplastic colorectal obstruction with colonic endoluminal stenting devices. Am J Surg 2001;181:499-506. 7. Fazio VW. Indications and surgical alternatives for palliation of rectal cancer. J Gastrointest Surg 2004;8:262-5. 8. Keymling M. Colorectal stenting. Endoscopy 2003;35:234-8. 9. Lee YM, Law WL, Chu KW, Poon RT. Emergency surgery for obstructing colorectal cancers: a comparison between right-sided and left-sided lesions. JAmCollSurg2001;192: 19-25. 10. Baron TH, Rey JF, Spinelli P. Expandable metal stent placement for malignant colorectal obstruction. Endoscopy 2002; 34:823-30. 11. Rosen SA, Buell JF, Yoshida A, Kazsuba S, Hurst R, Michelassi F, Millis JM, Posner MC. Initial presentation with stage IV colorectal cancer: how aggressive should we be? Arch Surg 2000;135:530-5. 12. Makela J, Haukipuro K, Laitinen S, Kairaluoma MI. Palliative operations for colorectal cancer. Dis Colon Rectum 1990; 33:846-50. 13. Liu SK, Church JM, Lavery IC, Fazio VW. Operation in patients with incurable colon cancer: is it worthwhile? Dis Colon Rectum 1997;40:11-4. 14. Joffe J, Gordon PH. Palliative resection for colorectal carcinoma. Dis Colon Rectum 1981;24:355-60. 15. Park JJ, Del Pino A, Orsay CP, Nelson RL, Pearl RK, Cintron JR, Abcarian H. Stoma complications: The Cook County Hospital experience. Dis Colon Rectum 1999;42:1575-80. 16. Nugent KP, Daniels P, Stewart B, Patankar R, Johnson CD. Quality of life in stoma patients. Dis Colon Rectum 1999;42: 1569-74. 17. Johnson R, Marsh R, Corson J, Seymour K. A comparison of two methods of palliation of large bowel obstruction due to irremovable colon cancer. Ann R Coll Surg Engl 2004;86: 99-103. 18. Bhardwaj R, Parker MC, Palliative therapy of colorectal carcinoma: stent or surgery? Colorectal Disease 2003;5: 518-21. 19. Xinopoulos D, Dimitroulopoulos D, Theodosopoulos T, Tsamakidis K, Bitsakou G, Plataniotis G, Gontikakis M, Kontis M, Paraskevas I, Vassilobpoulos P, Paraskevas E. Stenting or stoma creation for patients with inoperable malignant colonic obstructions? Surg Endosc 2004;18:421-6. 20. Khot UP, Lang AW, Murali K, Parker MC. Systematic review of the efficacy and safety of colorectal stents. Br J Surg 2002; 89:1096-102. 21. Sebastian S, Johnston S, Geoghegan T, Torreggiani W, Buckley M. Pooled analysis of the efficacy and safety of self-expanding metal stenting in malignant colorectal obstruction. Am J Gastroenterol 2004;99:2051-7. 22. Keymling M. Colorectal stenting. Endoscopy 2003;35:234-8. 23. Tsurumaru D, Hidaka H, Okada S, Sakoguchi T, Matsuda H, Matsumata T, Nomiyama H, Utsunomiya T, Irie H, Honda H. Self-expandable metallic stents as palliative treatment for malignant colorectal obstruction. Abdom Imaging 2007;32: 619-23. 24. Maetani I, Tada T, Ukita T, Inoue H, Yoshida M, Saida Y, Sakai Y. Self-expandable metallic stent placement as palliative treatment of obstructed colorectal carcinoma. JGastroenterol 2004;39:334-48. 25. Meisner S, Hensler M, Knop FK, West F, Wille-Jorgensen P. Self-expanding metal stents for colonic obstruction: experiences from 104 procedures in a single center. Dis Colon Rectum 2004;47:444-50. 26. Ptok H, Meyer F, Marusch F, Steinert R, Gastinger I, Lippert H, Meyer L. Palliative stent implantation in the treatment of malignant colorectal obstruction. Surg Endosc 2006;20: 909-14.